Early right ventricular systolic dysfunction in patients with systemic sclerosis without pulmonary hypertension: a Doppler Tissue and Speckle Tracking echocardiography study

Digital Ulcers and Ventricular Arrhythmias as Red Flags to Predict Replacement Myocardial Fibrosis in Systemic Sclerosis

BACKGROUND

Cardiac involvement in systemic sclerosis (SSc) affects the prognosis of the disease. Echocardiography is the first line imaging tool to detect cardiac involvement, but it is not able to routinely detect myocardial fibrosis. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is the gold standard for replacement myocardial fibrosis assessment, but its availability is currently limited.

AIM

We aimed to assess the clinical and instrumental parameters that would be useful for predicting the presence of LGE-CMR, to achieve a better selection of patients with SSc that could benefit from third-level CMR imaging.

METHODS

344 SSc patients underwent a comprehensive echocardiogram and LGE-CMR on the same day; for 189 patients, a 24 h ECG Holter monitoring was available.

RESULTS

CMR showed non-junctional replacement myocardial fibrosis via LGE in 25.1% patients. A history of digital ulcers (OR 2.188; 95% C.I. 1.069-4.481) and ventricular arrhythmias at ECG Holter monitoring (OR 3.086; 95% C.I. 1.191-7.998) were independent predictors of replacement myocardial fibrosis.

CONCLUSIONS

CMR can detect patterns of clinical and subclinical cardiac involvement, which are frequent in SSc. A history of digital ulcers and evidence of ventricular arrhythmias at ECG Holter monitoring are red flags for the presence of replacement myocardial fibrosis in CMR. The association between digital ulcers and myocardial fibrosis suggests that a similar pathological substrate of abnormal vascular function may underlie peripheral vascular and cardiac complications.

Primary Cardiac Involvement in Systemic Sclerosis

Primary cardiac involvement in systemic sclerosis (SSc) is an important cause of morbidity and mortality. Abnormalities of cardiac structure and function can be detected on routine cardiopulmonary screening that is the standard of care for SSc monitoring. Cardiovascular magnetic resonance-extracellular volume (indicating diffuse fibrosis) and cardiac biomarkers may identify at-risk patients who would benefit from further evaluation including screening for atrial and ventricular arrhythmias with implantable loop recorders. The role of algorithm-based cardiac evaluation both before and after therapeutic initiation is one of the many unmet needs for SSc clinical care.

Association between systemic sclerosis and left ventricle dysfunction: Findings from observational studies

Objectives

Cardiac involvement is common in systemic sclerosis (SSc) patients. In this study, we aimed to systematically evaluate the relationship between SSc and left ventricular dysfunction (LVD), especially the left ventricular diastolic dysfunction, by ultrasound and cardiac magnetic resonance data.

Methods

We searched The Cochrane Library, PubMed and Embase databases collected studies about comparing LVD parameters in SSc patients and controls from establishment to January 2022. Furthermore, we also performed a two-sample MR using summary statistics from genome-wide association studies (GWAS) important LVD parameters, including left ventricular end-diastolic volume (LVEDV), left ventricular mass (LVM) and left ventricular ejection fraction (LVEF).

Results

Our meta-analysis included 31 eligible studies with 1448 SSc patients. According to the results, SSc patients had lower peak of early diastolic flow velocity/peak of late diastolic flow velocity ratio (E/A ratio), E, trans-mitral early filling peak velocity (E'), and left ventricular end-diastolic diameter (LVEDD) compared to controls. The E/E' ratio, A, left ventricular isovolumetric relaxation time (IVRT), deceleration Time (DT) and left atrial (LA) diameter were higher in SSc patients in comparison with controls. Moreover, we observed that the SSc patients had lower LVEF than controls. And in MR analysis, we also found that SSc was causally correlated with LVEF (OR = 0.9966, 95% CI 0.9935-0.998, P = 0.0398). However, unfortunately, there was no significant correlation between SSC and LVM (OR = 1.0048, 95% CI 0.9919-1.0179, P = 0.4661) and LVEDV (LVEDV OR = 0.9976, 95%CI 0.9888-1.0066, P = 0.6019).

Conclusion

SSc patients had diastolic/systolic dysfunction. However, MR analysis cannot confirm the genetic relationship between SSc and LVDD because of insufficient data. More research is needed to confirm the causal relationship between the two.

Speckle tracking echocardiography in systemic sclerosis: A useful method for detection of myocardial involvement

BACKGROUND

Systemic sclerosis is a multisystem disorder characterized by tissue fibrosis and organ damage. Heart involvement is one of the main factors shortening survival, which may be underestimated by conventional echocardiography measurements. Two-dimensional speckle-tracking echocardiography is a powerful novel modality to assess subclinical myocardial dysfunction.

AIM

The aim of this study is to investigate heart involvement in systemic sclerosis patients, and to determine the usefulness of ventricular longitudinal deformation using the Two-dimensional speckle tracking technology for an early detection of ventricular dysfunction.

PATIENTS AND METHODS

Between May 2016 and September 2016, 25 patients with systemic sclerosis and 25 healthy subjects underwent echocardiography to assess heart abnormalities and the strain of the two ventricles using two dimensions' speckle tracking echography.

RESULTS

The two groups were comparable in age and gender. Despite comparable left ventricle systolic function (left ventricular ejection fraction patients 64.58±8.87 vs. in healthy 68.2±7.41, P=0.19), patients presented altered longitudinal peak systolic strain values (global longitudinal strain: patients -17.42±1.62 vs. healthy -19.24±8.85, P<0.0001). Despite comparable pulmonary artery systolic pressure, there was a significant alteration in right ventricular systolic and diastolic function assessed by standard measurement. Longitudinal peak systolic strain of the right ventricle was significantly lower in patients compared with controls (P<0.01).

CONCLUSION

Ventricular deformation analysis by two dimensions' speckle tracking echocardiography appears to be a sensitive method to detect early ventricular impairment in patients with systemic sclerosis.

Systolic Dysfunction in Systemic Sclerosis: Prevalence and Prognostic Implications

Objective

Primary cardiac involvement is presumed to account for a substantial part of disease-related mortality in systemic sclerosis (SSc). Still, there are knowledge gaps on the evolution and total burden of systolic dysfunction in SSc. Here we evaluated prospective left ventricular (LV) and right ventricular (RV) systolic function in an unselected SSc cohort and assessed the burden of systolic dysfunction on mortality.

Methods

From the Oslo University Hospital cohort, 277 SSc patients were included from 2003-2016 and compared with healthy controls. Serial echocardiographies were reevaluated in order to detect change in systolic function. Right heart catheterization was performed on patients suspected of pulmonary hypertension. Descriptive and regression analyses were conducted.

Results

At baseline, LV systolic dysfunction by ejection fraction less than 50%, or a global longitudinal strain greater than -17.0%, was found in 12% and 24%, respectively. RV systolic dysfunction measured by tricuspid annular plane systolic excursion (TAPSE) less than 17 mm was evident in 10%. Follow-up echocardiography was performed after a median of 3.3 years (interquartile range [IQR] 1.5-5.6). At follow-up, LV systolic function remained stable, whereas RV function evaluated by TAPSE deteriorated (mean 23.1 to 21.7 mm, P = 0.005) equaling a 15% prevalence of RV systolic dysfunction. RV systolic function predicted mortality in multivariable models (hazard ratio 0.41, 95% confidence interval [CI] 0.19-0.90, P value 0.027), whereas LV systolic function lost predictive significance when adjusted for TAPSE.

Conclusion

In this unselected and prospective study, systolic dysfunction of the LV and RV was a frequent complication of SSc. LV systolic function remained stable across the observation period, whereas RV function deteriorated and predicted mortality.

Evaluation of left and right ventricle by two-dimensional speckle tracking echocardiography in systemic sclerosis patients without overt cardiac disease

BACKGROUND/OBJECTIVE

The aim was to evaluate the left and right ventricular functions concurrently by two-dimensional speckle tracking echocardiography (STE) in systemic sclerosis (SSc) patients without overt cardiac disease.

METHODS

A total of 47 patients with SSc and 36 age- and sex-matched controls were evaluated cross-sectionally. Two-dimensional STE was used to assess the longitudinal peak systolic strains (PSS) of both ventricles including apical long-axis (APLAX), apical four-chamber (4-CH), apical two-chamber (2-CH), and global longitudinal measurements. Any association of metabolic, cardiac, and inflammatory biomarkers with PSS was investigated.

RESULTS

The longitudinal PSS of the left ventricle [APLAX, 4-CH, 2-CH and global] were significantly lower in SSc patients than controls (- 18.2 ± 3.2 vs - 19.8 ± 2.7% p = 0.02; - 17.8 ± 3.5 vs. - 20.3 ± 3.3% p = 0.001; - 18.6 ± 3.1 vs. - 21.8 ± 3% p < 0.001; - 17.5 ± 5.7 vs. - 20.6 ± 2.7% p = 0.003, respectively). No difference was found between the groups for right ventricular strains. The longitudinal PSS-4CH correlated positively with CRP and ESR (r = 0.349, p = 0.016; r = 0.356, p = 0.014, respectively) and negatively with serum Galectin-3 (r = - 0.362, p = 0.012). Global longitudinal PSS-left ventricle (LV) correlated positively with CRP and homocysteine (r = 0.297, p = 0.043; r = 0.313, p = 0.041, respectively) and negatively with serum Galectin-3 (r = -0.314, p = 0.041). After multivariable adjustment, CRP remained the only predictor of longitudinal PSS-4CH (95% CI 0.35, 0.70, p = 0.028) and global longitudinal PSS of left ventricle (95% CI 0.004, 0.22, p = 0.043).

CONCLUSIONS

Biventricular evaluation of patients with SSc by two dimensional STE revealed reduced left ventricular longitudinal strains, despite preserved right ventricular strain, and no diastolic dysfunction. In SSc without overt cardiac disease, global cardiac assessment with 2DSTE is a promising method which seems to contribute to the detection of patients without clinical findings.

KEY POINTS

• Two dimensional STE revealed reduced left ventricular longitudinal strains, despite preserved right ventricular strain in SSc patients without overt cardiac disease. • CRP was the predictor of decreased longitudinal strains. • Cardiac assessment in SSc should be made globally.

Global longitudinal strain measured by speckle tracking identifies subclinical heart involvement in patients with systemic sclerosis

Background Systemic sclerosis is characterised by progressive cutaneous and organ fibrosis. Among all organs, a subclinical heart involvement is difficult to detect through conventional imaging. Design We evaluated whether speckle tracking-derived global longitudinal strain could help detect early subclinical systolic dysfunction in systemic sclerosis patients without overt clinical involvement. Methods A case-control, single-centre study on 52 systemic sclerosis patients and 52 age and gender-matched controls. Patients with structural heart disease, heart failure, atrial fibrillation and pulmonary hypertension were excluded. For every patient, standard echocardiographic and speckle tracking-derived variables for the systolic and diastolic function of the left ventricle and right ventricle were acquired. Results Traditional parameters of left and right systolic function did not differ between systemic sclerosis patients and controls (all P = ns). Left and right ventricular global longitudinal strain was significantly impaired in patients with systemic sclerosis when compared to controls (-19.2% vs. -21.1%; P = 0.009 and -18.2% vs. -22.3%; P = 0.012, respectively). Systemic sclerosis patients had a 2.5-fold increased risk of subclinical left ventricular systolic impairment (odds ratio 2.5, 95% confidence interval 1.1-5.5; P = 0.027) and a 3.3-fold increased risk of subclinical right ventricular systolic impairment when compared to controls (odds ratio 3.3, 95% confidence interval 1.4-7.7; P = 0.004). Alterations in the myocardial deformation pattern of systemic sclerosis patients were homogeneous in the right ventricle and eccentric in the left ventricle. Conclusions While traditional echocardiographic parameters are ineffective in detecting subclinical systolic impairment, reduced global longitudinal strain is common in patients with systemic sclerosis and significant for both ventricles. Global longitudinal strain could become a low-cost, non-invasive and reliable tool in order to detect early cardiac involvement in systemic sclerosis patients.

Right Ventricle Remodeling and Function in Scleroderma Patients

Scleroderma, known also as systemic sclerosis (SSc), is a severe disease associated with high mortality rates, and right ventricular (RV) remodeling and dysfunction, along with pulmonary artery hypertension (PAH), are among the most important internal organ manifestations of this disease. PAH has a higher prevalence in patients with SSc compared to the general population and represents a significant predictor of mortality in SSc. In patients with SSc, the morphological remodeling and alteration of RV function begin even before the setting of PAH and lead to development of a specific adaptive pattern of the RV which is different from the one recorded in patients with IAPH. These alterations cause worse outcomes and increased mortality rates in SSc patients. Early detection of RV dysfunction and remodeling is possible using modern imaging tools currently available and can indicate the initiation of specific therapeutic measures before installation of PAH. The aim of this review is to summarize the current knowledge related to mechanisms involved in the remodeling and functional alteration of the RV in SSc patients.

Systemic sclerosis impacts right heart and cardiac autonomic nervous system

AIM

To evaluate the influence of systemic sclerosis (SSc) on right ventricular (RV) remodeling by two- and three-dimensional echocardiography (2DE and 3DE) and heart rate variability (HRV).

METHODS

Forty-five SSc patients and 35 age- and gender-matched healthy controls underwent clinical examination, 24-h Holter monitoring, and comprehensive 2DE and 3DE.

RESULTS

2DE RV global and RV free wall longitudinal strains, as well as 2DE RV endocardial, mid-myocardial, and epicardial longitudinal strains were lower in SSc subjects, who exhibited greater 3DE RV volumes but lower 3DE RV ejection fraction than controls. HRV indices were impaired in SSc subjects. These differences in RV global and free wall longitudinal strain, layer-specific strains, and ejection fraction, were associated with HRV indices independently of demographic, clinical, and echocardiographic parameters. Modified Rodnan Skin Score, clinical indicator of skin involvement in SSc, was associated with HRV parameters, RV layer-specific mechanics, and RV ejection fraction.

CONCLUSION

SSc affects RV function and mechanics of all myocardial layers, as well as cardiac autonomic nervous function. HRV indices are significantly associated with RV function, RV deformation, and skin involvement in SSc patients.

Pulmonary Arterial Hemodynamic Assessment by a Novel Index in Systemic Sclerosis Patients: Pulmonary Pulse Transit Time

OBJECTIVES

Systemic sclerosis (SSc) is a chronic, inflammatory, and autoimmune connective tissue disease that is associated with vascular lesions, and fibrosis of the skin and visceral organs. Cardiac complications may occur as a secondary effect of SSc as a result of pulmonary arterial hypertension and interstitial lung disease. The objective of this study was to assess whether the pulmonary pulse transit time (pPTT) could serve as a diagnostic marker for pulmonary arterial alterations in patients with SSc, prior to development of pulmonary hypertension.

METHODS

Twenty-five SSc patients as a study group and 25 age- and sex-matched healthy volunteers for the control group were recruited to the study. Right ventricle function parameters, such as tricuspid annular plane systolic excursion (TAPSE), estimated pulmonary artery systolic pressure (ePASP), right ventricular dimensions, right ventricle fractional area changes, and myocardial perfusion index (MPI) were measured and calculated. Pulmonary pulse transit time was defined as the time interval between the R-wave peak in the ECG and the corresponding peak late systolic pulmonary vein flow velocity.

RESULTS

Right ventricle myocardial performance index (RVMPI) and eSPAP were significantly higher in the SSc group than the controls (p = 0.032, p = 0.012, respectively). Pulmonary pulse transit time and TAPSE was shorter in the patients with SSc (p = 0.006, p = 0.015, respectively). In correlation analysis, pPTT was inversely correlated with RVMPI (r = - 0.435, p = 0.003), eSPAP (r = - 0.434, p = 0.003), and disease duration (r = - 0.595, p = 0.003). Conversely, it positively correlated with TAPSE (r = 0.345, p = 0.022).

CONCLUSION

pPTT was found to be shorter in SSc patients. pPTT might serve as a surrogate marker of pulmonary hemodynamics in patients with SSc, even prior to the development of pulmonary hypertension.

Update on assessment and management of primary cardiac involvement in systemic sclerosis

Primary cardiac involvement is a common and severe complication of systemic sclerosis, which may affect all of the hearts' structural components, including pericardium, myocardium, endocardium, cardiac valves, and conduction system. While cardiac disease can be clinically silent and only diagnosed in autopsy, new imaging modalities such as speckle-tracking echocardiography and cardiovascular magnetic resonance may reveal various abnormal findings in the majority of patients. Cardiovascular magnetic resonance evaluation should include assessment of left and right ventricular function, inflammation (STIR T2-weighted sequences (T2-W) for edema detection), and fibrosis (T1-weighted sequences 15 min after Gd-DTPA contrast medium injection (late-gadolinium enhancement). Notably, cardiac disease is responsible for about one-fourth of systemic sclerosis-related deaths. Systematic studies for the assessment and therapy of systemic sclerosis-related cardiac complications, as well as relevant guidelines from the European League Against Rheumatism and the American College of Rheumatology, are currently lacking. However, research advances reviewed herein allow for a better understanding of the mechanisms that alter cardiac function. Implementation of such knowledge should reduce cardiac morbidity and mortality in systemic sclerosis patients.

New Insights into Cardiac Involvement in Juvenile Scleroderma: A Three-Dimensional Echocardiographic Assessment Unveils Subclinical Ventricle Dysfunction

Cardiac manifestations in juvenile scleroderma or systemic sclerosis (JSSc) have poor prognosis, begin in early stages of the disease, and remain clinically asymptomatic. New echocardiography modalities, such as 2D/3D speckle tracking (STE, strain analysis for regional and global ventricular functions), can detect cardiac involvement in early stages. We assessed 21 JSSc patients and 19 controls using 2D/3D STE. The left ventricular end diastolic volume, end systolic volume, and ejection fraction of the patient and control groups were significantly different (99.2 ± 23.8 vs. 52 ± 23.8, 40.6 ± 16.0 vs. 20.2 ± 17.4 and 59.2 ± 7.5 vs. 65.6 ± 5.2, respectively). Global longitudinal strain (GLS) and global circumferential strain (GCS) were lower in the patient group (18.4 ± 4.7 vs. 22.4 ± 3.7, 26.4 ± 5.8 vs. 31.4 ± 3.5), as were the peak systolic strain values of the right ventricular longitudinal strain (RVLS) septum and RVLS free wall (18.1 ± 6.8 vs. 24.8 ± 6.0 and 22.8 ± 5.9 vs. 28.0 ± 6.9, respectively). 3D measurements of RVEDV, RVESV, and RVSV were higher in the patient group (88.2 ± 31.3 vs. 50.8 ± 23.5, 43.1 ± 17.6 vs. 19.0 ± 12.2, and 45.0 ± 16.2 vs. 31.7 ± 12.6). RVLS freewall results were lower in the JSSc patients with interstitial lung fibrosis, arthritis, muscle weakness, weight loss, and anti-scl 70 antibodies than in the JSSc patients without these variables. We found that a GCS of <34.5% could identify patients for left ventricular (LV) dysfunction with a sensitivity of 93.3, specificity of 92.9, while an RVEF of <60.7% could identify patients for left ventricular (RV) dysfunction with a sensitivity of 92.9 and specificity of 21.4%. We highlighted key advantages of 3D STE for the tracking of early systolic dysfunction in patients with JSSc who would benefit from medical intervention for cardiac complications.

Follow-Up of Pulmonary Hypertension With Echocardiography

Individual patient response to effective therapies for pulmonary hypertension (PAH) is variable and difficult to quantify. Consequently, management decisions regarding initiation and continuation of therapy are highly dependent on the results of investigations. Registry data show that changes in cardiac index, mean right atrial pressure, and mean pulmonary artery pressure have the greatest influence on survival. It is recognized that pulmonary artery pressure (PASP) responses to PAH-specific drugs are heterogeneous. However, follow-up testing is strongly focused on assessing changes in PASP and functional status (6-min walk). The goals of therapy, which should be highlighted in follow-up imaging, include not only reduction of PASP, decrease in pulmonary vascular resistance, and improvements in right ventricular function, cardiac output, and tricuspid regurgitation. This paper reviews the echocardiographic follow-up of pulmonary hypertension, and especially focuses on right ventricular function-a major determinant of outcome, for which reliable echocardiographic assessment has become more feasible.

Cardiac mechanics and heart rate variability in patients with systemic sclerosis: the association that we should not miss

We aimed to determine left ventricular (LV) and right ventricular (RV) structure, function and mechanics, as well as heart rate variability (HRV), and their relationship, in patients with systemic sclerosis (SSc). The study included 41 SSc patients and 30 age-matched healthy volunteers. All the patients underwent clinical examination, serological tests, pulmonary function testing, 24-h Holter monitoring and complete two-dimensional echocardiography including strain analysis. The parameters of LV structure (interventricular septum thickness and LV mass index) and RV structure (RV wall thickness) were significantly higher in SSc patients. LV and RV diastolic function (estimated by mitral and tricuspid E/e' ratio) was significantly impaired in SSc group comparing with the healthy controls. LV and RV longitudinal function was significantly deteriorated in SSc patients. LV circumferential strain was also significantly lower in SSc group, whereas LV radial strain was similar between the observed groups. All parameters of time and frequency domain of HRV were decreased in SSc patients. LV and RV cardiac remodeling parameters, particularly diastolic function and longitudinal strain, were associated with HRV indices without regard to the main demographic or the clinical and echocardiographic characteristics. Rodnan Skin Score was also independently associated with biventricular cardiac remodeling in SSc patients. LV and RV structure, function and mechanics, as well as autonomic nervous function, were significantly impaired in SSc patients. There is the significant association between biventricular cardiac remodeling and autonomic function in these patients, which could be useful for their everyday clinical assessment.

Prognostic value of transthoracic echocardiography and biomarkers of cardiac dysfunction in community-acquired pneumonia

The aim of this study was to determine the prognostic role of echocardiography and compare with admission N-terminal proB-type natriuretic peptide (NT-proBNP) levels in adult patients with community-acquired pneumonia (CAP). Consecutive adult patients hospitalized with CAP were prospectively enrolled and followed-up until hospital discharge or death. Echocardiography was performed within the first 48 hours. Complicated hospitalization (CH) was defined as intensive care unit admission, need for mechanical ventilation or in-hospital mortality. This study was registered with ClinicalTrials.gov, number NCT02441855. A total of 15 CH (13.5%) occurred among 111 patients with CAP. CAP patients with a CH compared with those without CH had significantly higher NT-proBNP values (1267.4±1146.1 vs. 305.6±545.7 pg/mL, p <0.001) and troponin I (23.8±24.3 vs. 10.3±6.3 ng/mL, p 0.02) but had lower left ventricle ejection fraction (52.7±8.7 vs. 60.5±6.7%, p <0.001) and tricuspid annular plane systolic excursion (TAPSE), which is a measure of right ventricular systolic function (17.1±4.4 vs. 21.8±4 mm; p 0.001). Patients with elevation of NT-proBNP and decreased TAPSE at presentation had a significantly higher probability of CH (60%) than patients with either elevated NT-proBNP or decreased TAPSE (40%). Patients with neither elevated NT-proBNP nor decreased TAPSE had a 0% probability of CH. This is the first study to demonstrate that decreased right ventricular systolic function is associated with increased rates of adverse events in patients with CAP.

A critical view on cardiovascular risk in systemic sclerosis

Systemic Sclerosis (SSc) is an autoimmune disorder characterized by microvascular injury and diffuse fibrosis of the skin and internal organs. While macrovascular disease and higher risk for cardiovascular events are well documented in other systemic rheumatic diseases such as rheumatoid arthritis and systemic lupus erythematosus, the presence and extent of atherosclerosis among patients with SSc is yet to be established. Primary cardiac involvement, due to impairment of coronary microvascular circulation and myocardial fibrosis, considerably affects prognosis and life expectancy of individuals with SSc, representing one of the leading causes of death in this population. On the other hand the existence and prevalence of atherosclerotic coronary disease remains an issue of debate as studies comparing structural and morphological markers of atherosclerosis and cardiovascular events between SSc patients and the general population have yielded controversial results. The aim of this review is to summarize recent literature about the prevalence of cardiovascular disease in SSc, review the surrogate markers of CVD that have been evaluated and examine whether common pathogenic mechanisms exist between SSc and macrovascular disease.

Risk factors for severity and manifestations in systemic sclerosis and prediction of disease course

Systemic sclerosis (SSc, or scleroderma) is a rheumatic disease with distinct features that encompass autoimmunity, vascular lesions (vasculopathy) and tissue fibrosis. The disease has a high morbidity and mortality compared with other rheumatic diseases. This review discusses risk factors and markers that predict the disease course and the occurrence of disease manifestations, with an emphasis on major organ involvement. In addition, risk factors will be described that are associated with mortality in SSc patients. The review addresses the impact of recent developments on screening, diagnosis and risk stratification as well as the need for further research where data are lacking.

The Role of Echocardiography in the Evaluation of Pulmonary Arterial Hypertension

The evaluation of pulmonary arterial hypertension (PAH) requires a multimodality approach that combines invasive and noninvasive imaging studies to ensure accurate diagnosis and classification. Given the complexity of the hemodynamic relationships between the left heart, pulmonary circulation, and right heart, the diagnosis of PAH is often a challenging task. Right heart catheterization is the gold standard for diagnosis, providing the hemodynamic information that defines the disease. Nonetheless, echocardiography continues to be a valuable tool in the approach to the patient with suspected PAH. Echocardiographic assessment generates a wealth of information about the response of the right heart to elevated pulmonary pressures and provides essential diagnostic and prognostic data to the clinician. Numerous measurements can be used to identify alterations in right heart morphology, pressure, and function; although each variable in isolation may have little utility, meaningful information is revealed when multiple parameters are considered together. In this article, we will review the echocardiographic measurements employed in assessment of the right heart and seek to clarify the role of echocardiography in the diagnostic workup of PAH.

Tissue Doppler-Derived Myocardial Acceleration during Isovolumetric Contraction Predicts Pulmonary Capillary Wedge Pressure in Patients with Significant Mitral Regurgitation

The aim of this study was to determine whether isovolumic contraction velocity (IVV) and acceleration (IVA) predict pulmonary capillary wedge pressure (PCWP) in mitral regurgitation. Forty-four patients with mitral regurgitation were studied. PCWP was invasively measured. IVV, IVA and the ratio IVRT/Te'-E (where IVRT = isovolumic relaxation time, and Te'-E = time difference between the onset of mitral annular e' and mitral flow E waves) were measured. Mean age was 59.2 ± 13.3 y. Twenty-six patients had an ejection fraction ≥55%, and 18 patients had an ejection fraction <55%. IVRT/Te'-E was impossible in 11 patients because Te'-E = zero. PCWP correlated with IVV, IVA and IVRT/Te'-E; overall (r = -0.714, -0.892 and, -0.752, all p < 0.001), ejection fraction ≥55 (r = -0.467, -0.749, -0.639, p = 0.016, <0.001, 0.003) and ejection fraction <55% (r = -0.761, -0.911 and -0.833, all p < 0.001). Similar correlations were found for sinus and atrial fibrillation. Our study suggests that IVV and IVA correlate with PCWP in patients with mitral regurgitation irrespective of systolic function or rhythms and, thus, can be alternatives to the tedious IVRT/Te'-E, especially when impossible because Te'-E = 0.

Association between right ventricular dysfunction and restrictive lung disease in childhood cancer survivors as measured by quantitative echocardiography

BACKGROUND

Restrictive lung disease is a complication in childhood cancer survivors who received lung-toxic chemotherapy and/or thoracic radiation. Left ventricular dysfunction is documented in these survivors, but less is known about right ventricular (RV) function. Quantitative echocardiography may help detect subclinical RV dysfunction. The aim of this study was to assess RV function quantitatively in childhood cancer survivors after lung-toxic therapy.

PROCEDURES

We identified records of 33 childhood cancer survivors who (1) were treated with lung-toxic therapy and/or radiation, (2) were cancer-free for ≥ one year after therapy, and (3) had pulmonary function tests and echocardiograms from their most recent follow-up visit.

RESULTS

Participants' mean age was 11.6 ± 4.5 years at cancer diagnosis and 23 ± 8.6 years at evaluation. The most common diagnosis was lymphoma/leukemia (n = 27). Twenty-nine subjects had anthracycline exposure. Eleven of the 33 subjects demonstrated restrictive pulmonary impairment (total lung capacity 3.69 ± 1.5 L [69.3 ± 22.4% predicted]). Among quantitative measures of RV function, isovolumetric acceleration (IVA), a measure of contractility, was significantly lower in the group with restrictive lung disease (2.42 ± 0.56 vs. 1.83 ± 0.78 m/sec(2); P < 0.05). There was a trend towards lower tissue Doppler derived S' and tricuspid annular plane systolic excursion in the group with restrictive lung disease. Subjects with restrictive lung disease were found to have ≥ 2 abnormal parameters (P < 0.01).

CONCLUSION

IVA may detect early RV dysfunction in childhood cancer survivors with restrictive lung disease. Our findings require confirmation in a larger study population and validation by cardiac MRI.

Evaluation of global function of the heart in scleroderma patients

OBJECTIVE

Scleroderma is a connective tissue disease characterized by diffuse vascular lesions and fibrosis of the skin and major organs including lungs, kidneys, and heart. When cardiac involvement is clinically evident, it is recognized as a poor prognostic factor. The early detection of cardiac involvement in scleroderma would be desirable both for implementation of preventive measures in the early stages of the disease and for optimal treatment.

METHODS

Left (LV) and right (RV) ventricular function were examined in 31 scleroderma patients and 21 healthy controls. Conventional and tissue Doppler echocardiography was used to evaluate systolic and diastolic function. Systolic indices including systolic (S) velocity, isovolumetric acceleration (IVA), ejection time (ET), and isovolumetric contraction time (IVCT) were measured. Early diastolic (E) velocity, late diastolic (A) velocity, E/A and E'/A' ratios, isovolumetric relaxation time (IVRT), and deceleration time (DT) were the diastolic measurements obtained. Myocardial performance index (Tei index) calculated by 2 different methods was used to assess global ventricular function.

RESULTS

In our study; mitral S velocity, biventricular ET, E', E/A, E'/A', RV IVA, LV IVA, and tricuspid S velocity were significantly lower in scleroderma patients. Mitral DT, IVCT, and biventricular IVRT, were significantly higher in scleroderma patients (P < 0.0001). In addition, RV and LV Tei indices were significantly increased in scleroderma patients compared with the control group (P < 0.0001 and P < 0.001, respectively).

CONCLUSIONS

In scleroderma patients, global function was depressed prior to the onset of clinical symptoms. Biventricular diastolic and systolic function abnormalities were also observed.

Left atrial dysfunction detected by speckle tracking in patients with systemic sclerosis

BACKGROUND

Cardiac involvement is a relevant clinical finding in systemic sclerosis (SSc) and is associated with poor prognosis. Left atrial (LA) remodeling and/or dysfunction can be an early sign of diastolic dysfunction. Two-dimensional speckle tracking echocardiography (STE) is a novel and promising tool for detecting very early changes in LA myocardial performance.

AIM

To assess whether STE strain parameters may detect early alterations in LA function in SSc patients.

METHODS

Forty-two SSc patients (Group 1, age 50 ± 14 years, 95% females) without clinical evidence for cardiac involvement and 42 age- and gender-matched control subjects (Group 2, age 49 ± 13 years, 95% females) were evaluated with comprehensive 2D and Doppler echocardiography, including tissue Doppler imaging analysis. Positive peak left atrial longitudinal strain (ϵ pos peak), second positive left atrial longitudinal strain (sec ϵ pos peak), and negative left atrial longitudinal strain (ϵ neg peak) were measured using a 12-segment model for the LA, by commercially available semi-automated 2D speckle-tracking software (EchoPac PC version 108.1.4, GE Healthcare, Horten, Norway).

RESULTS

All SSc patients had a normal left ventricular ejection fraction (63.1 ± 4%). SSc patients did not differ from controls in E/A (Group 1 = 1.1 ± 0.4 vs Group 2 = 1.3 ± 0.4, p = .14) or pulmonary arterial systolic pressure (Group 1 = 24.1 ± 8 mmHg vs Group 2 = 21 ± 7 mmHg, p = .17). SSc patients did not show significantly different indexed LA volumes (Group 1 = 24.9 ± 5.3 ml/m2 vs Group 2 = 24.7 ± 4.4 ml/m2, p = .8), whereas E/e' ratio was significantly higher in SSc (Group 1 = 7.6 ± 2.4 vs Group 2 = 6.5 ± 1.7, p<0.05), although still within normal values. LA strain values were significantly different between the two groups (ϵ pos peak Group 1 = 31.3 ± 4.2% vs Group 2 = 35.0 ± 7.6%, p < .01, sec ϵ pos peak Group 1 = 18.4 ± 4 vs Group 2 = 21.4 ± 7.6, p < 0.05).

CONCLUSION

2D speckle-tracking echocardiography is a sensitive tool to assess impairment of LA mechanics, which is detectable in absence of changes in LA size and volume, and may represent an early sign of cardiac involvement in patients with SSc.

Isolated right ventricular dysfunction in patients with human immunodeficiency virus

BACKGROUND

HIV-infected individuals are at increased risk for pulmonary hypertension and cardiomyopathy, portending a poor prognosis. Right ventricular (RV) dysfunction is associated with worse outcomes in these conditions, yet its prevalence is poorly defined in HIV. We sought to determine the prevalence of RV dysfunction in an outpatient HIV cohort.

METHODS

Echocardiograms were evaluated from 104 HIV-infected adults. Measurements included estimated pulmonary arterial systolic pressure (PASP) and several measures of RV function, including tricuspid annular plane systolic excursion (TAPSE), RV longitudinal myocardial strain (RVLMS), RV fractional area change (RVFAC), and myocardial performance index (MPI).

RESULTS

Sixteen subjects (15%) had PASP >35 mm Hg, yet RV function did not differ significantly from those with normal estimated PASP. RV dysfunction defined by RVFAC <35% occurred in 11%. RVLMS had a median value of -27.3%, and individuals below the median had lower TAPSE but no differences in left ventricular ejection fraction (LVEF), PASP, or other measures. Dyspnea was associated with the lowest quintile of RVLMS (≥-21.05%). There were 6 subjects with LVEF <50%, and these individuals had lower TAPSE but no differences in PASP or other RV functional measures.

CONCLUSIONS

RV dysfunction was common as estimated PASP >35 mm Hg and LV dysfunction, but these findings did not cosegregate. RV dysfunction in HIV-infected individuals may be a separate entity from LV/global cardiomyopathy or pulmonary hypertension and deserves further study.

Tissue Doppler imaging in systemic sclerosis: a 3-year longitudinal study

OBJECTIVES

To investigate by standard echocardiography and pulsed-tissue Doppler imaging (TDI) the course of systemic sclerosis (SSc) heart disease and its correlation with epidemiological, clinical, and serological features of the disease and drug treatment.

METHODS

A total of 74 consecutive patients (69 females, between the ages of 19 and 71 years, and disease duration 1-43 years) and 71 controls underwent cardiac assessment at baseline and at 3-year follow-up.

RESULTS

At baseline, compared to controls, patients showed post-Bonferroni correction, impaired left (LV) and right ventricular (RV) diastolic function (Em/Am 0.85 ± 0.4 vs 1.5 ± 0.7, p = 0.0003; Et/At 0.9 ± 0.3 vs 1.3 ± 0.4, p = 0.0003), subtle LV and RV systolic dysfunction (Sm 13.7 ± 2.7 vs 15.4 ± 3.2cm/s, p = 0.031; St < 11.5cm/s in 16/74 patients vs 0 controls, p = 0.0031), and higher pulmonary artery systolic pressure (sPAP) (26.1 ± 6.0 vs 24.1 ± 5.1, p = 0.040). At 3-year follow-up, SSc patients showed a further deterioration of biventricular diastolic and systolic function and a further sPAP increase. At multiple regression analysis of baseline data, Em/Am < 1 was detected in 55/74 patients vs 25/71 controls (p < 0.0001) and was associated with age (p = 0.030); Et/At < 1 was detected in 16/74 patients vs 7/71 controls (p < 0.0001), was associated with NYHA class ≥ II (p = 0.033), late capillaroscopic pattern (p = 0.029), and a baseline cardiac Medsger severity score ≥ 1 (p = 0.029). TDI evidence of new abnormalities in RV and/or LV diastolic function was associated with a baseline cardiac Medsger severity score ≥ 1 (p = 0.01). Neither diastolic or systolic abnormalities nor sPAP changes correlated with treatment.

CONCLUSIONS

Our study confirms that SSc patients exhibit biventricular systolic and diastolic dysfunction and increased sPAP and reveals further deterioration at 3-year follow-up.

Echocardiographic parameters in patients with pulmonary arterial hypertension: correlations with right ventricular ejection fraction derived from cardiac magnetic resonance and hemodynamics

BACKGROUND

Echocardiography is the most convenient method used to evaluate right ventricular function, and several echocardiographic parameters were studied in previous studies. But the value of these parameters to assess the right ventricular function in patients with pulmonary arterial hypertension (PAH) has not been well defined.

METHODS

Patients with PAH were observed prospectively. Right heart catheterization, echocardiography and cardiac magnetic resonance (CMR) were performed within 1 week interval. The correlations between echocardiographic parameters and right ventricular ejection fraction (RVEF) derived from CMR as well as hemodynamics were analyzed.

RESULTS

Thirty patients were enrolled including 24 with idiopathic PAH, 5 with PAH associated with connective tissue diseases and 1 with hereditary PAH. All echocardiographic parameters except right ventricular myocardial performance index (RVMPI) correlated significantly with RVEF (tricuspid annual plane systolic excursion [TAPSE], r = 0.440, P = 0.015; tricuspid annular systolic excursion velocity [S'], r = 0.444, P = 0.016; isovolumic acceleration [IVA], r = 0.600, P = 0.001; right ventricular fraction area change [RVFAC], r = 0.416, P = 0.022; ratio of right ventricular transverse diameter to left ventricular transverse diameter [RVETD/LVETD], r = -0.649, P<0.001; RVMPI, r = -0.027, P = 0.888). After adjusted for mean right atrial pressure, mean pulmonary arterial pressure and pulmonary vascular resistance (PVR), only IVA and RVETD/LVETD could independently predict RVEF. Four echocardiographic parameters displayed significant correlations with PVR (TAPSE, r = -0.615, P<0.001; S', r = -0.557, P = 0.002; RVFAC, r = -0.454, P = 0.012; RVETD/LVETD, r = 0.543, P = 0.002).

CONCLUSIONS

The echocardiographic parameters IVA and RVETD/LVETD can reflect RVEF independently regardless of hemodynamics in patients with PAH. In addition, TAPSE, S', RVFAC and RVETD/LVETD can also reflect PVR in PAH patients.

Role of 2D strain in the early identification of left ventricular dysfunction and in the risk stratification of systemic sclerosis patients

BACKGROUND

Systemic sclerosis (SSc) is an autoimmune chronic disease characterized by diffuse fibrosis involving several organs, including heart. Aim of our study was to analyze left ventricular (LV) myocardial deformation, by use of 2D strain, in asymptomatic SSc patients with normal LV ejection fraction.

METHODS

We enrolled 29 SSc patients (28 female, 65±4 years) and 30 controls (23 female, 64±2 years). Echocardiographic study with tissue Doppler imaging (TDI) and 2D strain analysis was performed; moreover, patients were submitted to a two-year follow-up for the occurrence of cardiovascular events.

RESULTS

Standard echocardiographic parameters and TDI velocities were comparable between groups. LV longitudinal (LS) and circumferential (CS) strains were lower in patients than in controls (-13.1±4.8 vs -22.6±4.1, p < 0.001; -15.3±6.2 vs -20.4±5.6, p = 0.001), whereas radial strain (RS) was comparable between groups; moreover, a significant correlation of LS and CS with serum levels of Scl-70 antibodies was found (r = 0.74, p = 0.001; r = 0.53, p = 0.025). In addition, patients with cardiovascular events during follow-up showed a greater impairment of LS and CS (-10.3±2.5 vs -14.4±4.1, p = 0.015; -14.2±3.1 vs -20.1±1.6, p = 0.048) and higher values of Scl-70 antibodies serum levels (p = 0.047).

CONCLUSION

The impairment of LV function, often subclinical, worsens prognosis of SSc patients, leading to increased risk of cardiovascular complications. 2D strain, allowing the early detection of LV abnormalities and the identification of patients at greater cardiovascular risk, may be a useful tool in order to provide a more accurate management of SSc patients.

Systemic sclerosis and the heart: current diagnosis and management

PURPOSE OF REVIEW

When present clinically, cardiac involvement in systemic sclerosis (SSc) is a major risk factor for death. It is therefore vitally important to understand the epidemiology, screening, diagnosis, and treatment of the cardiac manifestations of SSc.

RECENT FINDINGS

The epidemiology of cardiac involvement in SSc has been the subject of several recent studies. Most importantly, the prevalence of overt left ventricular (LV) systolic dysfunction and its associated risk factors have been defined, and patients with diffuse cutaneous SSc appear to be most susceptible to direct cardiac involvement. From a diagnostic and screening standpoint, tissue Doppler echocardiography and natriuretic peptides have provided fresh insight into subclinical cardiac dysfunction in SSc. Newer techniques, such as speckle-tracking echocardiography, diffuse myocardial fibrosis imaging, and absolute myocardial perfusion imaging, are poised to further advance our knowledge. Lastly, there is now consistent observational data to suggest a central role for calcium channel blockers in the treatment of microvascular ischemia and prevention of overt LV systolic dysfunction, although randomized controlled trials are lacking.

SUMMARY

Recent studies have improved our understanding of cardiac involvement in SSc. Nevertheless, key questions regarding screening, diagnosis, and treatment remain. Novel diagnostic techniques and multicenter studies should yield important new data, which will hopefully ultimately result in improved outcomes.